Healey Lodge Residential Home

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well-led – this means we looked for evidence that leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last assessment we rated this key question requires improvement. At this assessment the rating remains requires improvement. This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

The provider was in breach of legal regulation in relation to the governance of the service.

This service scored 50 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider did not have a clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not always understand the challenges and the needs of people and their communities. Work was needed to improve the culture of this service. More focus was put on certain people and for people that were not as vocal, they tended to get overlooked. More focus was needed on those who may not be able to communicate their wishes verbally and to ensure everyone is treated equally and fairly and have access to the same opportunities including activities and community outings.

Staff spoke positively of the culture of the service. They said, “It is a really lovely care home. If my family ever needed care I would 100 percent recommend here. There is a massively good culture, a lovely atmosphere where all the staff and residents (people using the service) bounce off each other. People and staff are happy to be here.” The nominated individual told us the key values for the service were to enable each and every person to live a fulfilling life and that there should be no barriers of improvement.

The provider did not have inclusive leaders at all levels who understood the context in which they delivered care, treatment and support, or who embodied the culture and values of their workforce and organisation. The registered manager and nominated individual held conflicting views on the management of the service. On several occasions, they contradicted one another. Records were not robust. For example, we saw evidence of staff meetings taking place but there was no detail on who attended these meetings. Where staff had raised concerns, there was no evidence of any follow up action and lessons learnt were not shared and discussed at staff meetings.

Staff surveys were given out, however, there was no analysis of the results or actions put in place where concerns had been raised. Supervisions were not being carried out as frequently as the providers policy states. Staff spoke positively of the registered manager. They said, “The (registered) manager is lovely and knowledgeable. She helps out when needed and has worked here for over 20 years.” However, some concerns were raised about leadership skills and managers making tough decisions when it came to staff discipline.

The provider fostered a culture where people felt they could speak up and their voice would be heard. Staff told us they were aware of the term freedom to speak up and felt the registered manager would act on any concerns. A suggestion box was in the hallway for both people and staff to use, should they wish to make any suggestions. The nominated individual told us staff were encouraged to speak up without fear of repercussions. A whistleblowing policy was in place but this did not contain important contact information to guide staff should they wish to raise a concern.

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them. Staff told us they were treated fairly. They said, “I think all staff are treated well and fairly. If we need any adjustments to working hours or shift patterns the (registered) manager is really supportive.” The nominated individual told us reasonable adjustments are person specific and would be evaluated should the need arise. There was an equality and diversity policy in place.

The provider did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate. A range of audits and quality checks were in place; however, they were not robust enough to identify the concerns found during the assessment process. The environmental audit identified the need for a lock to be fitted on the laundry room door. This was identified through audits in July and September 2025 and no action had been taken. The monthly incident report and analysis and falls report analysis were contradictory to the incident and accident reports and offered no analysis of how falls occurred and what action would be taken to help reduce future risks. The safeguarding audit was not accurate as it stated all staff had completed training in this area in the past 12 months and that there was a designated safeguarding lead in place, however, this was incorrect.

Policies were not accurate, and some policies had the name of another care home on. Some policies were not being followed including the health and safety and safeguarding policy. Some documents were not available during our site visits and some policies were not readily available on site and instead had to be printed by the nominated individual. Therefore, we could not be assured staff including the registered manager had access to these policies. There appeared to be a lack of oversight into the concerns found during our assessment process and the leadership team were not aware of some of the concerns found at the last inspection.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement. Partners told us the service worked well with them to ensure people received joined-up effective care. Relatives told us people could access the community if they wished to. Staff told us people did not currently attend any local community groups but they were looking into doing so in the near future.

The provider did not focus on continuous learning, innovation and improvement across the organisation and local system. They did not encourage creative ways of delivering equality of experience, outcome and quality of life for people. There was limited evidence of lessons learnt or discussions when things had gone wrong. When incidents occurred, there was no record of this being discussed with staff for learning or mitigation of future risks. There is a champion scheme at this service, but not all staff were aware of who was a champion and what their role was. Where policies stated the champion for that area should complete audits, this was not always the case.